Processing Claims Affected by Medicare Retroactive Enrollment

Guidance for providers directly billing Medicare for services provided to patients with retroactive Medicare enrollment dates

This bulletin applies to NC Medicaid Managed Care and NC Medicaid Direct.  

Effective January 24, 2024, providers have additional options for billing Medicare for services provided to patients with retroactive Medicare enrollment dates. The time for filing a claim will be extended if the Centers for Medicare & Medicaid Services (CMS) or one of its contractors determines that failure to meet the filing deadline is caused by all the following conditions: 

  1. At the time the service was furnished the beneficiary was not entitled to Medicare;  
  2. The beneficiary subsequently received notification of Medicare entitlement effective retroactively to or before the date of the furnished service; and
  3. A State Medicaid Agency recovered the Medicaid payment for the furnished service from a provider or supplier six months or more after the date of the furnished service.  

To qualify for this exception, the provider or supplier will need to provide the claims processing contractor with the following information:  

  • Documentation verifying the date that the State Medicaid Agency recouped money from the provider/supplier;
  • Documentation verifying that the beneficiary was retroactively entitled to Medicare to or before the date of the furnished service - e.g., an official Social Security Administration (SSA) letter to the beneficiary, or if an official SSA letter is not available, the contractor shall check the Common Working File (CFW) database and may interpret the CFW date of accretion and the CWF Medicare entitlement date for a beneficiary in order to verify a beneficiary’s retroactive entitlement;  
  • Documentation verifying the service/s furnished to the beneficiary and the date of the furnished service(s).  

If the contractor determines that all conditions described above are met, the contractor will notify the provider or supplier in writing that a filing extension will be allowed from the end of the sixth calendar month from the month in which the State Medicaid Agency recovered its money.

Providers may encounter situations where Medicare patient enrollment dates are approved or changed retroactively, extending coverage for services beyond the timely filing limit. Since retroactive enrollment is an established exception to the timely filing period, providers may submit these claims to Medicare for payment per Section 70.7.3 Retroactive Medicare Entitlement Involving State Medicaid Agencies.

For more detailed information, please review Medicare Learning Network Matters (MLN) Matters MM13402 on the CMS website and refer to the Processing Claims Affected by Retroactive Entitlement bulletin from CMS.  

Contact

NCTracks Call Center: 800-688-6696

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